Upper vs. Lower Extremity Veins for Vascular Access Devices
Upper extremity veins are the preferred sites for vascular access devices in most clinical scenarios, while lower extremity veins are generally avoided except in specific circumstances.
When to Use Upper Extremity Veins
- First-line choice: The veins of the hand, forearm, and upper arm (below the axilla) are recommended for peripheral venous access due to lower risks of complications, better dwell times, and increased patient comfort.
- Device longevity: Forearm veins are favored to increase device dwell time, reduce pain, promote self-care, and minimize accidental removal or occlusion.
- Complication avoidance: Upper extremity veins have a lower risk of tissue damage, thrombophlebitis, and ulceration compared to lower extremity veins.
- Types of devices:
- Short peripheral catheters (SPCs) for emergency or short-term access 24–48 hours.
- Long peripheral catheters (LPCs) or midline catheters for longer durations or difficult access.
- Peripherally inserted central catheters (PICCs) and ports for long-term or frequent therapy.
- Special considerations: Avoid upper extremity veins on the side of prior breast surgery with axillary node dissection, lymphedema, arteriovenous fistula/graft, or after radiation therapy; also avoid in chronic kidney disease if veins are needed for future dialysis access.
When to Use Lower Extremity Veins
- Generally avoided: Lower extremity veins are not recommended due to higher risks of tissue damage, thrombophlebitis, and ulceration.
- Exceptions: Use only when upper extremity access is not possible (e.g., in emergencies or when all upper extremity sites are exhausted).
- Patient risk factors: Avoid lower extremity access in patients at high risk for chronic lower extremity ulcers, such as those with chronic kidney disease, diabetes, or peripheral arterial disease.
Central Venous Access
- Preferred central sites: For central venous catheters, the subclavian vein is favored over the jugular or femoral veins to minimize infection risk, except in patients with specific contraindications (e.g., chronic kidney disease, risk of central vein stenosis).
- Femoral vein: Use only when other central access sites are not available, as femoral access carries higher infection and thrombosis risks.
Upper extremity veins are almost always preferred for vascular access, while lower extremity veins should only be used when absolutely necessary and for the shortest duration possible. Central venous access should follow infection risk guidelines, with the subclavian vein preferred over the femoral vein when feasible. Site selection should always be individualized based on patient history, therapy duration, and specific risk factors.
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References
Nickel, B. et al., (2024, January/ February) Infusion Therapy Standards of Practice 9th edition. Journal of Infusion Nursing. https://www.ins1.org/publications/infusion-therapy-standards-of-practice/
Pittiruti, M. et al., (2021, May 15) European recommendations on the proper indication and use of peripheral venous access devices (the ERPIUP consensus): A WoCoVA project. The Journal of Vascular Access. https://gavecelt.it/nuovo/sites/default/files/uploads/ERPIUP%202021.pdf
Vascular Access Devices: PICCs and Ports. Cystic Fibrosis Foundation. https://www.cff.org/managing-cf/vascular-access-devices-piccs-and-ports
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